The NHANES program suspended field operations in March 2020 due to the coronavirus disease 2019 (COVID-19) pandemic. As a result, data collection for the NHANES 2019-2020 cycle was not completed and the collected data are not nationally representative. Therefore, data collected from 2019 to March 2020 were combined with data from the NHANES 2017-2018 cycle to form a nationally representative sample of NHANES 2017-March 2020 pre-pandemic data. These data are available to the public. Please refer to the Analytic Notes section for more details on the use of the data.
Hepatitis viruses constitute a major public health problem because of the morbidity and mortality associated with the acute and chronic consequences of these infections. Because of the high rate of asymptomatic infection with these viruses, information about the prevalence of these diseases is needed to monitor prevention efforts. By testing a nationally representative sample of the U.S. population, NHANES will provide the most reliable estimates of age-specific prevalence needed to evaluate the effectiveness of the strategies to prevent these infections. In addition, NHANES provides the means to better define the epidemiology of other hepatitis viruses. NHANES testing for markers of infection with hepatitis viruses has been used to determine secular trends in infection rates across most age and racial/ethnic groups and has provided a national picture of the epidemiologic determinants of these infections.
Hepatitis is inflammation of the liver most often caused by a virus. Viral hepatitis is a major public health problem of global importance because of the ongoing transmission of viruses that cause the disease and increased morbidity and mortality associated with the acute and chronic consequences of these infections. Global and US goals have been established for elimination of viral hepatitis as a public health threat by 2030 (HHS Healthy People, 2022 and HHS 2020).
In the US, the most common types of viral hepatitis are hepatitis A, B, and C. Effective vaccines are available to help prevent hepatitis A and hepatitis B. No vaccine is available for hepatitis C; however, highly effective, well-tolerated treatment can cure hepatitis C virus infection. Hepatitis D virus infection is less common in the US and can occur only among persons with hepatitis B virus infection. Hepatitis E infection also is less common in the US. These five hepatitis viruses, also called hepatitides, are well-characterized for detection with laboratory assays and are monitored in U.S. public health surveillance systems.
NHANES viral hepatitis data are used to monitor progress toward goals in Healthy People and the HHS Viral Hepatitis National Strategic Plan, which in turn support US and global viral hepatitis elimination goals (HHS Healthy People, 2022 and NASEC, 2017). The viral hepatitis laboratory and interview components of NHANES complement data from outbreak, case-based surveillance, vital statistics, health care systems, and cohort studies that can provide timely, detailed, or longitudinal information for subnational geographic areas and disproportionately affected populations, such as persons experiencing homelessness or living in correctional facilities; however, these sources lack information available from NHANES, such as race, ethnicity, education, income, and health status and behaviors.
Viral hepatitis data from NHANES are available beginning with the Second NHANES conducted during 1976-1980 for hepatitis A and hepatitis B, and with the Third NHANES conducted during 1988-1994 for hepatitis C, hepatitis D and hepatitis E.
An estimated 300 million people worldwide are persistent carriers of hepatitis B virus (HBV). Infection with HBV results in a wide spectrum of acute and chronic liver diseases that may lead to cirrhosis and hepatocellular carcinoma. Co-infection with hepatitis D virus (HDV) in persons with acute or chronic hepatitis B virus (HBV) infection can lead to fulminant hepatitis.
Transmission of HBV occurs by percutaneous exposure to blood products and contaminated instruments, sexual contact and perinatally from HBV-infected mothers to their unborn child.
HBV infection produces an array of unique antigens and antibody responses that, in general, follow distinct serological patterns.
Hepatitis B surface antigen (HBsAg), derived from the viral envelope, is the first antigen to appear following infection and can be detected serologically as an aid in the laboratory diagnosis of acute HBV infection.
Hepatitis B core antibody (anti-HBc) is detectable shortly after the appearance of hepatitis B surface antigen (HBsAg). As the appearance of anti-HBsAg may be delayed after HBsAg clearance, anti-HBc is sometimes the only serological marker for HBV infection and potentially infectious blood. Anti-HBc is found in acute and chronic hepatitis B patients and also indicates past resolved infection.
The Delta antigen/antibody system (HDAg/Anti-HDV) is related to HBV infection but immunologically distinct from its known reactivities; it is the expression of the Delta virus (Hepatitis D Virus, HDV), a cause of severe liver disease in HBsAg carriers. HDV is a 35-37nm particle containing low molecular weight RNA and HDAg, with an outer coat of HBsAg obtained from HBV. HDV is a defective virus and its replication requires helper functions provided by HBV. HDAg has been detected in liver and in serum and induces a specific antibody response (anti-HDV antibodies) in both the IgG and IgM classes.
Tests for anti-HBc, HBsAg, and anti-HDV are conducted as part of the NHANES viral hepatitis component. In August 2025, a new variable (SSLBDHD) was added to reflect retesting of HDV using a different assay after concerns were raised about potential false positive results during original testing (see Description of Laboratory Methodology section for additional information).
Examined participants aged 6 years or older in the NHANES 2017-March 2020 pre-pandemic sample were eligible.
Hepatitis B core antibody (anti-HBc)
Hepatitis B core antibody is measured using the VITROS Anti-HBc assay, which is performed using the VITROS Anti-HBc Reagent Pack and VITROS Immunodiagnostic Products Anti-HBc Calibrator on the VITROS ECi/ECiQ or VITROS 3600 Immunodiagnostic System.
The hepatitis B core antibody test is performed on all examined participants aged 6 years and older while the hepatitis B surface antibody test is performed on all examined participants aged 2 years old and older (reported in P_HEPB_S).
Hepatitis B surface antigen (HBsAg)
Hepatitis B surface antigen is measured using the VITROS HBsAg test, which is performed using the VITROS HBsAg Reagent Pack and VITROS Immunodiagnostic Products HBsAg Calibrator on the VITROS ECi/ECiQ Immunodiagnostic Systems and the VITROS 3600 Immunodiagnostic System.
The Hepatitis B surface antigen is tested only when the Hepatitis B core antibody test is positive or indeterminate.
Hepatitis D antibody (anti-HDV) - original testing
Hepatitis D antibody was measured using the DiaSorin
ETI-AB-DELTAK-2 assay during 2017-2018 and the Anti-HDV IgG WES Assay during
January 2019 through March 2020.
The Hepatitis Delta Virus (HDV) is a RNA defective virus; and an infection with HDV only occurs in the presence of acute or chronic HBV infection. In NHANES, the test for antibody to HDV is performed on all examined participants 6 years and older who test positive or indeterminate for anti-HBc and HBsAg.
April 2025 anti-HDV retesting for 2007-2008, 2009-2010, 2011-2012, 2013-2014, 2015-2016, and 2017-2018 cycles
From 2007-2008 through 2017-2018, NHANES anti-HDV testing was performed with a DiaSorin enzyme immunoassay designated as Research Use Only in the United States because it was not approved for clinical use by the US Food and Drug Administration. Concerns about high rates of false positivity from this assay were raised after NHANES results showed a higher-than-expected number of positive results for hepatitis D antibody for certain cycles of data collection (Soriano, et al. 2019). The DiaSorin assay was removed from the market in 2019.
Unpublished replication of hepatitis D antibody testing results by CDC’s Division of Viral Hepatitis (DVH) staff confirmed that the reported high prevalence of HDV antibody was not due to incorrect analysis of data or to outlying or influential survey weights. Therefore, in April 2025, samples from 2007-2008 through 2017-2018 were retested. Retesting eligibility included participants with reactive/positive test results for hepatitis B surface antigen during 2007-2008 through 2017-2018 (because Hepatitis D viral infection and replication is only possible with co-infection with hepatitis B - see below “Analytic Notes” session) and with available surplus serum samples.
Retesting was performed with a different CLIA-validated hepatitis D virus antibody assay, International Immunodiagnostics HDV Ab (IID HDV Ab) ELISA, that was approved for use at CDC in 2023. This assay is a competitive enzyme immunoassay (EIA) for the determination of antibodies to HDV in human serum with a “one-step” methodology. Antibodies to HDV, if present in the sample, compete with a virus-specific polyclonal IgG/IgM (Total antibodies), labeled with Horseradish peroxidase (HRP), for a fixed amount of recombinant HDV protein coated on the microplate. The concentration of the bound enzyme on the solid phase is inversely proportional to the amount of HDV antibodies in the sample and its activity is detected by adding the chromogen/substrate in the second incubation.
Refer to the Laboratory Method Files section for a detailed description of the laboratory methods used.
Hepatitis B Core Antibody (February 2020)
Hepatitis B Surface Antigen (February 2020)
Hepatitis D Antibody (February 2020)
Hepatitis D Antibody (August 2022)
Hepatitis B Surface Antigen (August 2022)
Hepatitis B Core Antibody (August 2022)
Hepatitis D Antibody (April 2025) - Retesting Method (January 2026)
Serum samples were processed, stored, and shipped to the Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA for analysis.
Detailed instructions on specimen collection and processing are discussed in the 2017-2018 and 2019-2020 NHANES Laboratory Procedures Manuals (LPMs). Vials were stored under appropriate frozen (–30°C) conditions until they were shipped to Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention for testing.
The NHANES quality assurance and quality control (QA/QC) protocols meet the 1988 Clinical Laboratory Improvement Act mandates. Detailed QA/QC instructions are discussed in the NHANES LPMs.
Mobile Examination Centers (MECs)
Laboratory team performance is monitored using several techniques. NCHS and contract consultants use a structured competency assessment evaluation during visits to evaluate both the quality of the laboratory work and the QC procedures. Each laboratory staff member is observed for equipment operation, specimen collection and preparation; testing procedures and constructive feedback are given to each staff member. Formal retraining sessions are conducted annually to ensure that required skill levels were maintained.
Analytical Laboratories
NHANES uses several methods to monitor the quality of the analyses performed by the contract laboratories. In the MEC, these methods include performing blind split samples collected on “dry run” sessions. In addition, contract laboratories randomly perform repeat testing on 2% of all specimens.
The data were reviewed. Incomplete data or improbable values were sent to the performing laboratory for confirmation.
The COVID-19 pandemic required suspension of NHANES 2019-2020 field operations in March 2020 after data were collected in 18 of the 30 survey locations in the 2019-2020 sample. Data collection was cancelled for the remaining 12 locations. Because the collected data from 18 locations were not nationally representative, these data were combined with data from the previous cycle (2017-2018) to create a 2017-March 2020 pre-pandemic data file. A special weighting process was applied to the 2017-March 2020 pre-pandemic data file. The resulting sample weights in the demographic data file should be used to calculate estimates from the combined cycles. These sample weights are not appropriate for independent analyses of the 2019-2020 data and will not yield nationally representative results for either the 2017-2018 data alone or the 2019-March 2020 data alone. Please refer to the NHANES website for additional information for the NHANES 2017-March 2020 pre-pandemic data, and for the previous 2017-2018 public use data file with specific weights for that 2-year cycle.
Refer to the 2017-2018 and 2019-2020 Laboratory Data Overview for general information on NHANES laboratory data.
There are over 800 laboratory tests performed on NHANES participants. However, not all participants provided biospecimens or enough volume for all the tests to be performed. The specimen availability can also vary by age or other population characteristics. For example, in 2017-March 2020 approximately 76% of children aged 1-17 years who were examined in the MEC provided a blood specimen through phlebotomy, while 95% of examined adults aged 18 and older provided a blood specimen. Analysts should evaluate the extent of missing data in the dataset related to the outcome of interest as well as any predictor variables used in the analyses to determine whether additional re-weighting for item non-response is necessary.
Please refer to the NHANES Analytic Guidelines and the on-line NHANES Tutorial for further details on the use of sample weights and other analytic issues.
Demographic and Other Related Variables
The analysis of NHANES laboratory data must be conducted using the appropriate survey design and demographic variables. The NHANES 2017 – March 2020 Demographics File contains demographic data, health indicators, and other related information collected during household interviews as well as the sample design variables. The recommended procedure for variance estimation requires use of stratum and PSU variables (SDMVSTRA and SDMVPSU, respectively) in the demographic data file.
This laboratory data file can be linked to the other NHANES data files using the unique survey participant identifier (i.e., SEQN).
Detection Limits
This data is qualitative. The use of lower limits of detection (LLODs) is not applicable.
The age range and constraints for Hepatitis B and D testing are as follows:
Hepatitis B
The hepatitis B core antibody test is performed on all examined participants aged 6 years and older while the hepatitis B surface antibody test is performed on all examined participants aged 2 years old and older. The Hepatitis B surface antigen is tested only when the Hepatitis B core antibody test is positive. Participant results are coded positive for surface antigen if the surface antigen test is positive; they are coded negative for surface antigen if the test for surface antigen is negative or if the test for hepatitis B core antibody is negative.
Hepatitis D
Hepatitis D virus (HDV), or delta infection, occurs only in the presence of acute or chronic HBV infection because delta requires HBV components to enter liver cells, assemble, and make new virus. In NHANES, the test for antibody to HDV is performed on all examined participants 6 years and older who test positive or indeterminate for anti-HBc and HBsAg. Participant results were coded positive for hepatitis D antibody if the HDV antibody test was positive; they were coded negative for hepatitis D antibody if the HDV antibody test was negative, or if no test for HDV antibody was performed because the anti-HBc or HBsAg tests were negative.
Hepatitis D Antibody (Delta) Method Change
The method for Hepatitis D Antibody (delta) changed between survey cycles 2017-2018 and 2019-2020. The commercial kit (Diasorin) used during the 2017-2018 survey cycle was discontinued by the manufacturer. A CDC laboratory developed test was used in 2019-2020 survey cycle and had a sensitivity of 96% and a specificity of 97%. The sensitivity and specificity for this newly developed method are verified using a convenience sample of NHANES specimens and non-NHANES specimens tested previously using the commercially available kit.
For the results from 2025 retesting, the following codes were used:
0 = HBsAg+ participants with no stored serum available, thus no re-testing could be performed.
1 = HBsAg+ participants with stored serum available and re-tested as positive (reactive) to the hepatitis D antibody.
2 = HBsAg+ participants with stored serum available and re-tested as negative (non-reactive) to the hepatitis D antibody.
6 = HBsAg- participants who were originally not tested and presumed negative to the hepatitis D antibody; no re-testing was performed because presumed negative.
. = Participants with a missing blood sample for the original testing were coded as missing for the re-testing as well.
| Code or Value | Value Description | Count | Cumulative | Skip to Item |
|---|---|---|---|---|
| 1 | Positive | 641 | 641 | |
| 2 | Negative | 10275 | 10916 | |
| 3 | Indeterminate | 1 | 10917 | |
| . | Missing | 1281 | 12198 |
| Code or Value | Value Description | Count | Cumulative | Skip to Item |
|---|---|---|---|---|
| 1 | Positive | 45 | 45 | |
| 2 | Negative | 10870 | 10915 | |
| 3 | Indeterminate | 0 | 10915 | |
| . | Missing | 1283 | 12198 |
| Code or Value | Value Description | Count | Cumulative | Skip to Item |
|---|---|---|---|---|
| 1 | Positive | 6 | 6 | |
| 2 | Negative | 10908 | 10914 | |
| 3 | Indeterminate | 0 | 10914 | |
| . | Missing | 1284 | 12198 |
| Code or Value | Value Description | Count | Cumulative | Skip to Item |
|---|---|---|---|---|
| 0 | Hep B sAg positive, no surplus sample | 24 | 24 | |
| 1 | Hep B sAg positive, reactive | 0 | 24 | |
| 2 | Hep B sAg positive, non-reactive | 20 | 44 | |
| 6 | Hep B sAg negative, not retested | 10870 | 10914 | |
| . | Missing | 1284 | 12198 |